Presentation and response of patients with upper extremity repetitive use syndrome to a multidisciplinary rehabilitation program: a retrospective review of 24 cases.

OBJECTIVE: To analyze retrospectively a group of patients presenting to an outpatient hand rehabilitation clinic with complaints related to repetitive tasks of the upper extremity. DESIGN: Retrospective case study reviewing 24 consecutive cases for presenting symptoms and response of patients to a multidisciplinary rehabilitation approach. SETTING: An outpatient hand rehabilitation clinic in a tertiary referral center offering simultaneous medical, psychological, and occupational evaluations. PATIENTS: Twenty-four patients with upper extremity symptoms related to repetitive use, who had all failed various prior therapeutic interventions. Fifty percent of the patients were receiving medical disability compensation because of their symptoms. Sixty-two percent had filed a worker's compensation claim. INTERVENTIONS: Treatment consisted of medical management with pharmacologic interventions, occupational therapy with workplace simulation and job-site evaluations, and psychological treatment with pain management and biofeedback training. Treatments were individualized to meet each patient's needs. OUTCOME MEASURES: Reduction in symptom intensity or frequency, increase in work and performance of activities of daily living, and termination of medical disability with return to work. RESULTS: Most cases (83%) were found to be related to occupational computer keyboard use. Bilateral hand and forearm pain were the major symptoms. A unique physical finding was diffuse tendon tenderness and tightness of the long flexor and extensor muscles of the forearm. Carpal tunnel syndrome was found in only one patient. Twenty-five percent of patients achieved resolution of most symptoms, although on a modified and often reduced activity level; 54% had moderate improvement; and 13% had only minimal or no improvement. Of the patients receiving medical disability compensation, 58% returned to their previous jobs. CONCLUSIONS: Patients with upper extremity symptoms related to repetitive use often have unique physical findings, distinct from those of carpal tunnel syndrome. Resulting work disability is high. Patients who have not responded to conventional interventions within a reasonable time may benefit from a multidisciplinary treatment approach. Most patients improve with this treatment but do not fully recover.

Development of polyarthritis after insertion of silicone breast implants followed by remission after implant removal in 2 HLA-identical sisters bearing rheumatoid arthritis susceptibility genes.

We describe 2 HLA-identical sisters who both received silicone breast implants and subsequently developed polyarticular arthritis and neurologic symptoms. In both patients, HLA typing revealed 3 alleles typically associated with rheumatic diseases: HLA-DRB1*0405 and HLA-DQB1*0302 (associated with RA), and HLA-DRB4*01 (associated with mixed connective tissue disease and autoimmune reactions in patients with silicone breast implants. After removal of the implants, rheumatic as well as neurologic symptoms improved dramatically in both patients. One patient achieved complete remission. The other patient, who initially had more progressive disease, retained mild residual symptoms, but had significant improvement in radiological erosions. We believe that our cases support the theories that silicone may act as a triggering factor in genetically susceptible individuals, and that silicone may represent an adjuvant for the development of autoimmune disease. We discuss the possibility that a manifested spectrum of symptoms after silicone exposure might be more specific for a patient's genetic background than unique for silicone.

Novel autoantibodies against muscle-cell membrane proteins in patients with myositis.

OBJECTIVE: To search for autoantibodies against muscle cell-specific surface membrane antigens in patients with inflammatory myopathies. METHODS: A cell enzyme-linked immunosorbent assay (cell ELISA) using a human rhabdomyosarcoma cell line (TE-671) was developed and performed in serial dilutions with either nonfixed or fixed cells. A total of 141 different patient sera were tested: 90 from patients with various rheumatic diseases, 12 from patients with cardiomyopathies, 25 from patients with other muscular diseases, and 14 from patients who had undergone major surgery or who had other noninflammatory diseases. As controls, 20 sera were obtained from healthy donors. Results were correlated using immunofluorescence staining and flow cytometry. RESULTS: Using the nonfixed cell ELISA, the proportions of positive sera from the patient groups with rheumatic diseases were 71% with polymyositis (PM), 15% with dermatomyositis (DM), 18% with systemic sclerosis (SSc), 15% with systemic lupus erythematosus (SLE), and 7% with rheumatoid arthritis. Sera from healthy donors, as well as sera from patients with nonrheumatic diseases, did not show significant reactivities. When other cell lines, including a chondrosarcoma, a bladder carcinoma, a pancreas carcinoma, and human foreskin fibroblasts, were used as substrates, positive sera did not react in the cell ELISA. Results obtained with the cell ELISA system using nonfixed cells were confirmed by flow cytometry and immunofluorescence staining. A strong protein band of 50 kd was detected on plasma membrane preparations from TE-671 muscle cells in 33% of PM sera (n = 12). CONCLUSION: In most sera from patients with PM, DM, and some other rheumatic diseases (i.e., SSc and SLE), autoantibodies directed against muscle-cell surface antigens can be detected. Since these molecules are localized in the muscle-cell surface membrane, autoantibodies directed against these antigens could play a major role in the pathogenesis of PM.

[Mechanism of action of gold in treatment of rheumatoid arthritis]. / Wirkmechanismen von Gold bei der Behandlung der rheumatoiden Arthritis.

Gold is one of the oldest and most effective drugs in the treatment of rheumatoid arthritis. Gold unfolds its therapeutic efficacy through various influences on the immune system. Gold alters antigen-processing and reduces cytokine expression of macrophages. Additionally, gold reduces adhesion molecules, antibody production and inhibits proteolytic enzymes. However, macrophages also oxidize gold(I) to gold(III) which is - by its increased protein reactivity - responsible for a large part of the gold side-effects.

Specific drugs for a complex disease: can there be a magic bullet against rheumatoid arthritis?

The complexity of RA challenges our search for a better understanding of the interconnected networks. Early treatment will certainly avoid some of the problems presented by the complexity of the disease, and combined treatments seem advantageous for advanced disease. The complexity of overt RA will probably not allow a single agent to exert superior efficacy. Unless a treatable infectious cause is identified, a magic bullet, though theoretically possible, might not exist in reality, in particular if the disease is advanced.

The impact of continuous subcutaneous infusion of octreotide on gallstone formation in acromegalic patients.

Treatment of acromegaly with intermittent sc injections of octreotide is associated with an increased incidence of cholelithiasis. We investigated the incidence of gallstone formation, the occurrence of gallbladder disease, and the response of gallstones to ursodeoxycholic acid in 30 acromegalic patients who were treated with a continuous sc infusion of octreotide at doses between 200 and 800 micrograms/day for 3-70 months. Of the 30 patients, 28 had pretretment ultrasonography of the biliary tree performed, and all had frequent follow-ups. Nine patients underwent pre- and posttreatment bile sampling. No patient treated for less than 6 months and 18.5% of patients treated for more than 6 months developed new gallstones. No patient developed symptomatic cholelithiasis while receiving octreotide therapy. Of six patients who developed gallstones, four were treated with ursodeoxycholic acid, which dissolved all gallstones. One patient with gallstones experienced an episode of biliary colic when octreotide was withdrawn; however, no cholecystitis was found at subsequent cholecystectomy. Bile sampling showed that 8 (75%) of the 12 patients who were assessed demonstrated microcrystals, whereas in 3 (50%) of 6 patients who were closely analyzed thereafter, microcrystals disappeared once octreotide therapy was stopped. Our results show that continuous sc infusion octreotide therapy increases the incidence of cholelithiasis over normal values, as is the case with intermittent sc injections. Although higher octreotide levels are sustained with continuous sc infusion, this is not associated with an increased risk of gallstone formation compared with intermittent sc octreotide therapy.

Liver transplantation in patients with systemic lupus erythematosus.

Liver transplantation has never been reported in patients with systemic lupus erythematosus (SLE). At our medical center, three patients with SLE underwent transplantation and it was successful in two of them. Management considerations germane to SLE are reviewed.

False-positive human immunodeficiency virus testing in patients with lupus erythematosus.

Testing for human immunodeficiency virus (HIV) infection in patients with systemic lupus erythematosus (SLE) leads to a higher than expected rate of positive ELISA results and indeterminate Western blot results. Because most of these patients lack any risk factors for HIV infection and the coexistence of SLE and HIV infection is extremely rare, most of these results represent false-positives. Two cases of false-positive HIV tests are reported and the related literature is reviewed. Further, Celum's algorithm for evaluating indeterminate HIV Western blot tests, which is especially valuable in lupus patients, is discussed.